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The Triangle of Wound Assessment
An Intuitive wound assessment and documentation tool for nurses and other healthcare professionals working with wounds.
Why wound assessment is important
The Triangle of Wound Assessment is a holistic framework that allows practitioners to assess and manage all areas of the wound, including the periwound skin.
It is a simple and systematic approach that guides the Health Care Professional from complete wound assessment to setting management goals and selecting relevant treatment options.
Structured and consistent wound assessment and documentation is important to guide your wound management goals and identify your treatment choices. Without a standardised framework or tool, it can be difficult to monitor the progress of wound healing. In fact, inadequate wound assessment may lead to delayed wound healing and can have a lasting impact on a patient’s quality of life.
Wound assessment is therefore not only important for healthcare professionals, but also for the wellbeing of the patient. By following a structured wound assessment tool, you will be able to document the wound healing progression and enable an easier hand over of care to other healthcare professionals.
We asked healthcare professionals around the world about their priorities for wound care.
We found that most people treating wounds are not specialists in a hospital1.
Up to 79% of wounds are being treated in the community2
Respondents said that protecting the periwound skin is very important1
Approximately 70% of wounds are surrounded by unhealthy skin3
However, in a recent study of 14 wound assessment tools...
...none met all of the criteria for optimal wound assessment4
The Triangle of Wound Assessment offers a systematic approach to wound management
Optimal wound management starts with a holistic wound assessment. 6,7,8 This will help to more efficiently set management goals, which will increase the potential for better treatment outcomes
What is wound assessment?
Wound assessment is an essential part of wound management and can be defined as: information obtained using observation, questioning, physical examination, and clinical investigations in order to formulate a management plan. Wound assessment should be comprehensive and holistic, performed at each patient visit/dressing change and should cover the following key elements:
- Assessment of the patient and social context
- Assessment of the wound bed
- Assessment of the wound edge
- Assessment of the periwound skin
Completing a comprehensive wound assessment, will guide you in correct identification of wound management goals and selection of evidence based wound treatments and interventions.
Holistic wound assessment covering all areas of the wound
The Triangle of Wound Assessment identifies three distinct, yet interconnected, areas, which call for different approaches:
Wound bed
Look for signs of granulation tissue, while seeking to remove dead or devitalised tissue, manage exudate level and reduce the bioburden in the wound.
Wound edge
Lower barriers to wound healing by reducing undermining for dead space, debriding thickened or rolled edges, and improving exudate management to minimise risk of maceration.
Periwound skin
Rehydrate dry skin and avoid exposure to exudate/moisture to minimise the potential for damage.